(An article on a similar topic was submitted to the Canadian Association of Speech-Language Pathologists and Audiologists)

Angela Roberts-South, Speech-Language Pathologist
National Parkinson Foundation Centre of Excellence, London Health Sciences Centre
PhD Student, School of Communication Sciences and Disorders
University of Western Ontario
London, Ontario

Traditionally the role of exercise has fallen under the realms of physiotherapy, occupational therapy and nursing. However, new research suggests that exercise may have a role in remedying areas that speech-language therapy traditionally targets, such as cognition, language, voice and swallowing in Parkinson’s.Exercise is accepted as a part of a healthy lifestyle. Of late, researchers are questioning the value of exercise in actually preventing and slowing the progression of Parkinson’s disease.

Cognition and language

Cognitive impairment is a Parkinson’s symptom with substantial effects on quality of life. Cognitive changes may begin early in the disease and may even precede motor symptoms for some people. These changes may affect language functions in ways that are evident on language assessments and particularly noticeable in conversation and in dual-tasking activities such as walking and talking.

While there is research showing that exercise is beneficial for cognition in Alzheimer’s disease, to date, there are no large randomized controlled trials to help answer this question in Parkinson’s. However, a few studies provide some insight into the potential benefits of exercise on cognition and language in Parkinson’s.

• Nocera, et al. (2010) reported the case of a woman with Parkinson’s who showed improved cognitive and language function following an exercise program that included 20 minutes of stationary bike riding, three times a week for eight weeks. In addition to substantial gains in executive function, working memory and verbal fluency, the researchers reported language improvements, such as more efficient and effective communication. The subject produced fewer grammatical errors and showed an impressive reduction in fluency interruptions and fillers (e.g., “uh”; “um”), which may reflect a reduction in word retrieval difficulties.
• In a study published by Cruise, et al. (2011), 34 people with Parkinson’s were allocated to either an exercise group or a control group. The exercise group participated in a 60-minute exercise session (cardiovascular and strength training) twice a week. In cognition and language areas, such as spatial working memory, verbal fluency and semantic fluency, the researchers reported that the exercise group showed gains that met statistical criteria for clinical substantial benefit.

These studies suggest a potential benefit of general exercise on cognition and language that is worth further investigation.

Voice and swallowing

Lee Silverman Voice Treatment^® (LSVT) is probably the most prominently reported targeted exercise program. It is an intensive exercise program performed by an LSVT-certified therapist. It involves following a prescribed exercise and stimulus protocol targeting the laryngeal and respiratory systems and mouth opening. Many studies have reported the benefits of LSVT on voice intensity. Recent research suggests that LSVT may also benefit swallowing (Sharkawi, et al., 2002).Voice and swallowing problems are common in Parkinson’s. There are no published studies evaluating the effect of general physical exercise programs, such as cardiovascular and strength training, on improvements in voice and swallowing in Parkinson’s. However, Russell, et al. (2010) published an excellent comprehensive review of targeted exercise programs in Parkinson’s. General physical exercise programs do not target a specific muscle group or motor target. Russell, et al. defined targeted physical exercise as the “systematic, repeated and controlled activation of particular groups of muscles for particular sequences of goal-directed actions.”

• Expiratory Muscle Strength Training (EMST), developed by Dr. Christine Sapienza, is another targeted exercise program. (The expiratory muscles are used in coughing.) EMST uses a specially-developed device and a prescribed exercise program to improve expiratory muscle function, which may have benefits for respiration and swallowing in Parkinson’s (Saleem, et al. 2005, Pitts, et al. 2009, Troche, et al. 2010). While EMST requires a special device, it can largely be completed at home unsupervised. A therapist is needed to calibrate the device and evaluate or re-set therapy targets.

Outside of LSVT and EMST, the literature on targeted, systematic exercise programs for voice and swallowing in Parkinson’s is sparse. There are other exercise programs reported in the literature but they have either failed to meet expected gains or failed to demonstrate carryover into functional activities. This makes it difficult for health professionals to apply them effectively in clinical settings.

Summary

There is a shortage of evidence on the benefit of exercise programs for cognition, language, voice and swallowing in Parkinson’s. Exercise targets, intensity and duration differed in the studies reviewed, however, there were some promising improvements in cognition and language with general exercise/fitness programs. As well, certain targeted exercise programs appear to demonstrate benefit.

Physical exercise programs are not often considered a companion to traditional speech-language therapy in Parkinson’s. However, it is possible that, as more research is completed, speech-language pathologists may need to increase their knowledge of both the application and development of targeted exercise programs and their knowledge of the adjunctive benefits of general physical exercise so they can incorporate it into therapy plans for people with Parkinson’s.